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 **U.S. Railroad Retirement Board**
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 Statement of Authority to Act for Employee (Form SI-10)
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          Sickness Benefits for Railroad Employees
          Instructions for Completing Forms
          Statement of Authority to Act for Employee (Form SI-10)
 Topics
    

      
              Introduction
          Qualification Requirements
          Amount and Duration of Benefits
          Eligibility Requirements
          Medical Statements
          Sick Pay and Supplemental Sickness Benefits
          Disqualifications
          Benefit Reductions
          Personal Injury Settlements
          Reconsideration and Waiver
          When Sickness Benefits are Taxable
          Instructions for Completing Forms
                                General Instructions
          Important Informtion
          Application for Sickness Benefits (Form SI-1a)
          Statement of Sickness (Form SI-1b)
          Statement of Authority to Act for Employee (Form SI-10)
          Claim for Sickness Benefits (Form SI-3)
          Notices
          Checking Your Benefits by Telephone
          Important Reminders Statement of Authority to Act for Employee (Form SI-10)
							 
							
							
            Completion of Form SI-10, Statement of Authority to Act for Employee, is not required for an employee who can sign papers or can sign by a mark and who understands transactions related to his or her application for benefits.

**Section 1 - Statement of Individual Acting for Employee**

This section is to be completed by the individual who signed the SI-1a, Application for Sickness Benefits, and who will act on behalf of the employee. Enter the employee's name, social security number, and address. Briefly explain why you believe the employee is incapable, and enter your relationship to the employee. If you are not related to the employee by blood or marriage, state your relationship and explain why no relative is acting for the employee. For example, an employee's foreman might explain: "My relationship to the employee is his foreman. He has no immediate family."

Completing Form SI-10, gives the signer the authority to sign any claim form on behalf of the employee.

When signing claim forms use your full name, and beneath your signature write "On behalf of" and the employee's full name.

**Section 2 - Statement of Employee's Doctor**
Have the employee's medical doctor complete this section.
        ‹ Statement of Sickness (Form SI-1b) | 
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 Last updated: 05/25/2017